Pediatric Orthopaedics Practice Questions

Q: What is the initial treatment for a newborn with congenital talipes equinovarus (CTEV)?

Manipulation and strapping or serial casting. **Explanation:** **Congenital Talipes Equinovarus (CTEV)**, or clubfoot, is a complex deformity involving four components: **C**aveus, **A**dduction, **V**arus, and **E**quinus (mnemonic: **CAVE**). 1. **Why Option B is correct:** The gold standard for initial management in a newborn is conservative treatment. This involves the **Ponseti method**, which consists of weekly **serial casting** and manipulation. The goal is to utilize the biological plasticity of a newborn's ligaments and tendons to gradually correct the deformity. Treatment should ideally begin within the first week of life. 2. **Why other options are incorrect:** * **Jess Fixation (A):** This is a fractional distractor (external fixator) used for neglected or recurrent clubfoot in older children, not as a primary treatment for newborns. * **Posteromedial Soft Tissue Release (PMSTR) (C):** This is a surgical intervention reserved for cases resistant to conservative management, typically performed between 6–12 months of age. * **Triple Arthrodesis (D):** This is a salvage procedure involving the fusion of three joints (subtalar, calcaneocuboid, and talonavicular). It is only performed in skeletal mature patients (usually >10–12 years) for severe, neglected, or paralytic deformities. **High-Yield Clinical Pearls for NEET-PG:** * **Order of Correction (Ponseti):** Caveus → Adduction → Varus → Equinus (**CAVE**). * **The "Last" Deformity:** Equinus is the last to be corrected and often requires a **Percutaneous Achilles Tenotomy** (performed in ~85% of cases). * **Maintenance:** After casting, a **Dennis Browne Splint** (foot abduction brace) is used to prevent recurrence. * **Pirani Score:** Used to assess the severity and monitor progress during serial casting.

Q: Fracture neck of femur in children is treated by:

Spica cast in abduction and internal rotation. **Explanation:** Fracture neck of femur in children is a high-energy injury and a surgical emergency due to the precarious blood supply to the developing femoral head [1]. The primary goal of treatment is stable reduction to prevent **Avascular Necrosis (AVN)** and **Coxa Vara**. **Why Option B is Correct:** For undisplaced fractures (Delbet Type II, III, and IV) or as a post-operative stabilizer after internal fixation, a **Spica cast in abduction and internal rotation** is the standard of care [1]. * **Abduction** places the femoral head securely into the acetabulum (congruency) and neutralizes the varus-producing forces of the abductor muscles. * **Internal rotation** helps in achieving anatomical alignment by compensating for the natural anteversion of the femoral neck, effectively "locking" the fracture fragments into a stable position. **Why Other Options are Wrong:** * **Option A & D (Adduction):** Adduction is contraindicated as it increases the risk of **Coxa Vara** (a common complication) by allowing the distal fragment to ride upward. * **Option C (External Rotation):** External rotation is the typical deformity position of a hip fracture; maintaining this would result in malunion and significant gait abnormalities. **NEET-PG High-Yield Pearls:** 1. **Delbet Classification:** The most important prognostic factor. Type I (Transepiphyseal) has the highest risk of AVN (~80-100%) [1]. 2. **Most Common Type:** Type II (Transcervical) [1]. 3. **Most Common Complication:** AVN (Avascular Necrosis), followed by Coxa Vara [1]. 4. **Management Rule:** Unlike adults, even minimally displaced fractures in children often require **urgent internal fixation** (using cannulated screws or wires) because the thick periosteum and high intra-articular pressure can easily compromise blood flow [1]. Cast alone is reserved only for strictly undisplaced fractures in very young children [1].

Q: All are true statements about talipes equinovarus, EXCEPT:

Treatment should start after 3 months. **Explanation:** **Talipes Equinovarus (TEV)**, commonly known as Clubfoot, is a congenital deformity characterized by four specific components represented by the mnemonic **CAVE**: **C**avus, **A**dduction (forefoot), **V**arus (hindfoot), and **E**quinus. **Why Option D is the correct answer (The Exception):** The gold standard for TEV management is the **Ponseti method**. Treatment should ideally begin **as soon as possible after birth**, typically within the first week of life. Delaying treatment until 3 months makes the soft tissues less pliable, increases the difficulty of manual correction, and often necessitates more invasive surgical intervention rather than serial casting. **Analysis of Incorrect Options:** * **Option A & B:** Inversion and forefoot adduction are core clinical components of the deformity. The hindfoot is in varus (inversion) and the forefoot is adducted at the midtarsal joints. * **Option C:** While most cases are idiopathic, TEV can be **secondary** to neuromuscular conditions. **Arthrogryposis Multiplex Congenita** is a well-known cause of rigid, syndromic clubfoot that is often resistant to standard casting. **High-Yield Clinical Pearls for NEET-PG:** * **Order of Correction (Ponseti):** Remember **CAVE** in reverse—**C**avus first, then **A**dduction and **V**arus simultaneously, and **E**quinus last (often requiring a percutaneous Achilles tenotomy). * **Radiology:** Kite’s angle (talocalcaneal angle) is **decreased** (<20°) on both AP and lateral views. * **Maintenance:** After casting, a **Steenbeek or Denis Browne splint** is used (23 hours/day for 3 months, then at night for 3–4 years) to prevent recurrence.

Q: What is the most common mode of inheritance for Achondroplasia?

Autosomal dominant. **Explanation:** **Achondroplasia** is the most common cause of disproportionate short-limb dwarfism. The correct answer is **Autosomal Dominant (B)** because the condition is caused by a gain-of-function mutation in the **FGFR3 gene** (Fibroblast Growth Factor Receptor 3) located on chromosome 4p. This mutation leads to constant inhibition of chondrocyte proliferation at the epiphyseal growth plate, resulting in impaired endochondral ossification. **Why other options are incorrect:** * **Sporadic (A):** While approximately **80% of cases** arise from *de novo* (new) mutations—often associated with advanced paternal age—the **mode of inheritance** itself is classified as Autosomal Dominant. If an affected individual has children, the trait follows a dominant pattern. * **Autosomal Recessive (C) & X-linked Recessive (D):** These do not apply to Achondroplasia. However, it is important to note that homozygous inheritance (two dominant alleles) is lethal in the neonatal period. **High-Yield Clinical Pearls for NEET-PG:** * **Genetics:** Specifically, a point mutation (G380R) in the FGFR3 gene. * **Clinical Features:** Rhizomelic shortening (proximal limb segments), "Trident hand" (persistent space between 3rd and 4th fingers), frontal bossing, and lumbar lordosis. * **Radiology:** Narrowing of the interpedicular distance (caudally), "Champagne glass" pelvis, and "Square" iliac wings. * **Intelligence:** Patients typically have normal intelligence and a normal lifespan. * **Complication:** Foramen magnum stenosis is a critical risk in infancy, potentially leading to sudden death or hydrocephalus.

Q: In a 2-year-old child, gallows traction is applied. The child is suffering from a fracture of which bone?

Fracture shaft of femur. ### Explanation **Correct Option: C. Fracture shaft of femur** **Gallows traction** (also known as **Bryant’s traction**) is a specific type of skin traction used primarily for the management of **femoral shaft fractures** in children. The underlying medical concept involves suspending the child’s lower limbs vertically using skin traction. The weight of the child’s body acts as the counter-traction. For this to be effective and safe, the child must weigh **less than 12–15 kg** and be **under 2 years of age**. The traction is applied such that the buttocks are just lifted off the bed (enough to pass a hand underneath), ensuring constant traction on the femur to maintain alignment and length. **Why other options are incorrect:** * **Neck of femur (A):** Pediatric femoral neck fractures are rare and are orthopedic emergencies usually requiring internal fixation (e.g., cannulated screws) due to the high risk of avascular necrosis (AVN). * **Greater trochanter (B):** Isolated fractures of the trochanter are usually avulsion injuries and do not require vertical suspension traction. * **Shaft of tibia (D):** Tibial fractures in toddlers are typically managed with an above-knee cast (e.g., Toddler’s fracture). Gallows traction is biomechanically designed for the femur. **High-Yield Clinical Pearls for NEET-PG:** * **Age/Weight Limit:** Strictly for children <2 years and <15 kg. * **Vascular Warning:** The most critical complication to monitor is **ischemia** of the feet. Frequent neurovascular checks are mandatory to prevent compartment syndrome or peroneal nerve palsy. * **Alternative:** For children older than 2 years with femur fractures, **Thomas splint** or **Spica casting** is preferred. * **Counter-traction:** Provided by the child's own body weight.

Q: A ten-year-old girl presents with swelling of one knee joint. All of the following conditions can be considered in the differential diagnosis, EXCEPT:

Haemophilia. **Explanation:** The correct answer is **Haemophilia (Option C)**. **1. Why Haemophilia is the correct answer:** Haemophilia is an X-linked recessive disorder, meaning it almost exclusively affects **males**. While females can be carriers, it is extremely rare for a female to present with clinical manifestations like hemarthrosis (bleeding into joints). Since the patient in the question is a **ten-year-old girl**, haemophilia is the least likely diagnosis among the choices provided. **2. Analysis of Incorrect Options:** * **Tuberculosis (Option A):** Monoarticular involvement of the knee is a classic presentation of skeletal TB in children. It typically presents with chronic swelling, synovial thickening, and "cold" abscess formation. * **Juvenile Idiopathic Arthritis (Option B):** JIA frequently presents in young girls. The pauciarticular (oligoarticular) subtype commonly involves large joints like the knee and is the most common cause of chronic arthritis in children. * **Pigmented Villonodular Synovitis (PVNS) (Option D):** This is a benign but aggressive proliferative condition of the synovium. It usually presents as chronic, painless, or mildly painful swelling of a single joint (most commonly the knee) and can occur in the pediatric age group. **3. Clinical Pearls for NEET-PG:** * **Gender Rule:** Always check the gender in orthopaedic questions. Haemophilia = Males; Developmental Dysplasia of the Hip (DDH) = Females (8:1). * **Monoarthritis in Children:** If acute, think Septic Arthritis; if chronic, think TB or JIA. * **PVNS Hallmark:** MRI shows "blooming" effect on T2-weighted images due to hemosiderin deposits. * **TB Knee:** Look for **Triple Deformity** (Flexion, Posterior subluxation, and External rotation).

Q: Which of the following is NOT true about Duchenne Muscular Dystrophy?

Distal muscle weakness is the primary finding.. **Explanation:** Duchenne Muscular Dystrophy (DMD) is an X-linked recessive disorder caused by a mutation in the **dystrophin gene**, leading to progressive muscle degeneration. **Why Option C is correct:** In DMD, the primary finding is **proximal muscle weakness**, not distal. Weakness typically begins in the pelvic girdle and hip extensors, later progressing to the shoulder girdle. Distal muscle strength is usually preserved until the advanced stages of the disease. **Analysis of other options:** * **Option A:** **Calf pseudohypertrophy** is a hallmark sign. The calves appear enlarged, but this is due to the replacement of muscle tissue with fat and connective tissue (fibrosis), rather than true muscle hypertrophy. * **Option B:** **Gower’s sign** is a classic clinical manifestation. Due to weak hip extensors (proximal weakness), the child must use their hands to "walk up" their legs to achieve a standing position from the floor. * **Option D:** Dystrophin is also absent in cardiac muscle. Most patients develop **dilated cardiomyopathy** and arrhythmias, with heart failure or respiratory failure being the leading causes of mortality. **High-Yield Clinical Pearls for NEET-PG:** * **Inheritance:** X-linked recessive (affects males; females are carriers). * **Biochemical Marker:** Significantly elevated **Serum Creatine Kinase (CPK)** levels (often 10–100x normal). * **Diagnosis:** Genetic testing (deletion analysis) is the gold standard; muscle biopsy shows absent dystrophin. * **Maneuver:** Trendelenburg gait is often present early due to gluteus medius weakness. * **Becker Muscular Dystrophy (BMD):** A milder form where dystrophin is truncated/reduced rather than absent; it has a later onset.

Q: Perthes disease most commonly affects which age group?

4 - 8 years. **Explanation:** **Legg-Calvé-Perthes Disease (LCPD)** is an idiopathic avascular necrosis of the femoral head occurring in children. The correct answer is **4–8 years** because this is the peak period of skeletal development where the blood supply to the femoral head is most vulnerable. During this window, the lateral epiphyseal artery (a branch of the medial circumflex femoral artery) is the primary source of nutrition, and its temporary interruption leads to bone ischemia and subsequent remodeling. **Analysis of Options:** * **Less than 4 years (Option A):** While it can occur in toddlers, it is rare. Prognosis is generally excellent in this age group due to the high remodeling potential of the immature skeleton. * **10–25 years (Option C):** This age group is more characteristic of **Slipped Capital Femoral Epiphysis (SCFE)**, which typically affects adolescents (10–16 years). Avascular necrosis in young adults is usually secondary to trauma or steroids, not idiopathic Perthes. * **Greater than 25 years (Option D):** Idiopathic Perthes is strictly a pediatric condition. AVN in adults is a distinct clinical entity with different etiologies (e.g., alcoholism, sickle cell, or trauma). **High-Yield Clinical Pearls for NEET-PG:** * **Gender:** More common in **boys** (4:1 ratio). * **Presentation:** Painless limp or hip/knee pain with restricted **abduction and internal rotation**. * **Radiology:** Look for the **"Crescent sign"** (subchondral fracture) and the **Gage sign** (V-shaped lucency on the lateral side of the epiphysis). * **Prognosis:** The most important prognostic factor is the **age at onset**; children younger than 6 years generally have better outcomes. * **Classification:** Catterall, Herring (Lateral Pillar), and Salter-Thompson are used to grade severity.

Q: Sprengel's deformity is a defect of?

Congenital elevation of scapula. ### Explanation **Correct Answer: C. Congenital elevation of scapula** **Understanding Sprengel’s Deformity** Sprengel’s deformity is the most common congenital anomaly of the shoulder girdle. It results from a **failure of the scapula to descend** from its embryonic position in the neck (where it originates at the level of C5-T1) to its normal thoracic position during the 9th to 12th week of gestation. Consequently, the scapula remains high, hypoplastic, and medially rotated. **Analysis of Options:** * **Option A (Absence of clavicle):** This is characteristic of **Cleidocranial Dysplasia**, a condition involving defective intramembranous ossification, often associated with dental anomalies and patent fontanelles. * **Option B & D (AC dislocation / Recurrent shoulder dislocation):** These are typically traumatic or instability-related conditions seen in adults or adolescents, not congenital developmental defects. **High-Yield Clinical Pearls for NEET-PG:** * **Omovertebral Bone:** Present in about 30% of cases. It is a fibrous, cartilaginous, or bony connection between the superior angle of the scapula and the cervical spine (usually C4-C7). * **Associated Anomalies:** Frequently associated with **Klippel-Feil Syndrome** (fused cervical vertebrae), scoliosis, and rib anomalies. * **Clinical Presentation:** Restricted shoulder abduction (due to scapulothoracic tethering) and cosmetic deformity (short neck appearance). * **Treatment:** Mild cases are managed conservatively. Severe cases (Green’s classification) require surgical procedures like the **Woodward procedure** or **Green’s procedure** to surgically lower the scapula.

Question 1

What is the initial treatment for a newborn with congenital talipes equinovarus (CTEV)?

Accepted Answer

Manipulation and strapping or serial casting

Answer

Jess fixation

Answer

Posteromedial soft tissue release

Answer

Triple arthrodesis

Question 2

Fracture neck of femur in children is treated by:

Accepted Answer

Spica cast in abduction and internal rotation

Answer

Spica cast in internal rotation and adduction

Answer

Spica cast in abduction and external rotation

Answer

Spica cast in flexion and adduction

Question 3

All are true statements about talipes equinovarus, EXCEPT:

Accepted Answer

Treatment should start after 3 months

Answer

Inversion of the foot

Answer

Adduction of the forefoot

Answer

Anrogryposis multiplex congenita causes it

Question 4

Which of the following statements is NOT true about Perthes disease?

Accepted Answer

Femoral valgus derotation osteotomy

Answer

Chiari osteotomy

Answer

Coxa plana

Answer

More common in females

Question 5

What is the most common mode of inheritance for Achondroplasia?

Accepted Answer

Autosomal dominant

Answer

Sporadic

Answer

Autosomal recessive

Answer

X-linked recessive

Question 6

In a 2-year-old child, gallows traction is applied. The child is suffering from a fracture of which bone?

Accepted Answer

Fracture shaft of femur

Answer

Neck of femur

Answer

Greater trochanter of femur

Answer

Shaft of tibia

Question 7

A ten-year-old girl presents with swelling of one knee joint. All of the following conditions can be considered in the differential diagnosis, EXCEPT:

Accepted Answer

Haemophilia

Answer

Tuberculosis

Answer

Juvenile rheumatoid arthritis

Answer

Villonodular synovitis

Question 8

Which of the following is NOT true about Duchenne Muscular Dystrophy?

Accepted Answer

Distal muscle weakness is the primary finding.

Answer

Calf pseudohypertrophy is present.

Answer

The patient uses their hands to climb up their body when rising from a seated position (Gower's sign).

Answer

Cardiomyopathy and congestive heart failure are common complications.

Question 9

Perthes disease most commonly affects which age group?

Accepted Answer

4 - 8 years

Answer

Less than 4 years

Answer

10 - 25 years

Answer

Greater than 25 years

Question 10

Sprengel's deformity is a defect of?

Accepted Answer

Congenital elevation of scapula

Answer

Absence of clavicle

Answer

Acromioclavicular dislocation

Answer

Recurrent dislocation of shoulder

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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